Antibiotics [pre:Dfreq, post: D dose by 50%]



Everything

And anything

Fill in IMR: Allergies. Diet. Old meds.

Fill inT&N: x hourly parameters. Trace old notes.

Passive things: From most to least important

(1)(a)Collapse,(b)Chest pain, (c)SOB: See below

(2)(a)Resite plug, (b)timed bloods/ECGs

(3)(a)Accompany DIL patient here and there for nonurgent stuff

(b)Pain here and there, fever, cannot sleep, etc

(4)Reviewing results: Scan for major abN: K+, Cardiac Enz(Cenz), Hb, Plt, XR reports. Leave exotic Ix for “team to note cm”. Compare with previous Ix, check if team left instructions in casefile/IMR.

(5)(a)Talking to relatives(if you like, else ask them come cm), (b)AOR d/c – Need MO to sign. just do the prescription, TCU and memo. d/c summary only for coroner’s case & interhospital/dept transfers.

Brainless blood taking

2 tubes = FBC, U/E/Cr. 3rd=PT/PTT. 4th=GXM.

Chest/SOB/Abd pain: Ck/CKMB/Trop T +/- Amylase, LFT

Consider LFT, Ca/Mg/PO4, drug levels

Fever: Blood C/S + Fever Ix(see fever)

SOB: ABG on whatever O2 pt looks comfortable on

2 plain and 1 PT/PTT(sterile fashion) for good measure.

-> PT/PTT can transfer to FBC/HBA1c, serology, GXM, C/S.

Cardio

AMI

Ix: 4tubes, CK, CKMB, Trop T+Bedside TropT, +/- LFT, +/- ABG. CXR, ECG: ST elevation +/- Q waves. R sided leads if ?Inf AMI.

NB: Trop T increased in CRF, recent AMI. CKMB/CK ratio > 5%.

Rx: O2. CRIB. Aspirin 300mg x1, then 100mg om [CI: BGIT, anemia ?cause], else Ticlid 250mg om. GTN ‘/’ S/L or patch stat.[CI: low BP] ISDN 10mg tds. Atenolol 100mg om [CI:asthma]. Captopril 12.5mg bd if ant AMI. Major MI: add Morphine 5mg i/v + maxalon. Atenolol 5mg i/v over 5 min. ISDN 2-10mg/h i/v. Urgent cardio r/v if good premorb & major MI.

CCF

Ix: 2tubes, CEnz, LFT, +/-ABG, ECG, CXR

Rx: Fluid restrict 1L/day. i/n O2, I/O chart, RIB

iv Lasix 40-80mg x1 + 40mg bd, spanK 0.6g om

Chest pain (on call)

Read case notes: PMH, current dx, recent ECG/CE.

Hx/PE: Nature of pain: cardiac/pleuritic/musculoskeletal

Ix: ECG(ST elevation, Q waves, then T inversion), cardiac enz.

Rx: as per AMI abv

Collapse/CPR

Determine “status” over phone. See stat anyway.

A,B : 100% O2 Bag, Dentures, Oral airway.Synchronize if breathing.

C: No pulse = pump 5:1. i/v access + 5mls bld & h/c. i/v N/S 1( fast.

- Asytole: 1mg adrenaline (“1 adrenaline”) + 1 mg atropine x 3

- VT/VF: off GTN, defib pads, align apex. Clear. 200J, check rhythm, 360, check, 360 then adrenaline 1mg, lignocaine 70mg

- PEA/EMD: Tx as for K+ (. Excl pneumothorax, cardiac tamponade.

If still no response & no help: Check premorbid, case sheet.

- Intubate: Preoxy. Wear mask. ETT: Males: Size 8 to 22-24cm. Fem: Size 7.5 to 20-22cm. Visualize, intubate, check both lungs, SaO2.

- I/v HCO3 50mls after 5 mins.

DIM

Alcohol intoxication

Ix: 3 tubes, alc toxi (document no alcohol swab), +/- green tube.

Rx: Valium 2mg, 2mg, 5mg for Delirium tremors.

Folate 10mg om, Vit B Co ‘/’ bd, Thiamine 30mg om

Allergic reaction (acute)

Stop offending medication (if identified), secure airway

Oral rx: Piriton ‘/’ stat, predisolone 10-30mg

IV rx: Promethazine 25-50mg , Hydrocortisone 100mg stat

Cellulitis

Ix: 2 tubes, Bld C/S, wound swab. Hba1c(DM)/Fasting h/c

4 tubes, ref ortho for abscess, OM, necrotizing fasc, wet gangrene.

Rx: (1)i/v Clox 1g 6h, (2)i/v ampi 1g 6h or CP 2mU 6h. Paracet.

Fever (while on call)

< 38.0: sponge, paracetamol

38+, already on antibiotics: Paracet,

38+, no source, no ab: Hx, PE, kiv septic workup & ab.

- lungs, urine, gut, plug site, op site, DVT, bedsores, cellulitis

38+, post op D1-2. Excl DVT, observe. Don’t open wound.

Hypotension (while on call)

Order 1( N/S(no K+) fast over phone. Confirm BP. Dx type of shock.

Ix: 4 tubes, +/- CK, CKMB, ECG, +/- DIVC screen, +/- lactate

Rx: O2, Fluids fast (> 2L unless in CCF). Call MO if still poor response. Kiv dopamin 1-10(g/kg/min. kiv CVP. Kiv PCT.

Poisoning

Ix: 4 tubes, LFT, toxicology (green tube, urine, sign 4 seals and fill form). ABG(Salicylates), levels(paracet/salicylate/etc)

police case, refer MSW, suicide precau

Rx: Lavage [50mg/L

Salicylate. If lvls > 3.6mM, give 1.26% bicarb +/- hemodi. Cx=Fits(diazepam), Acidosis(bicarb)

Naloxone 2mg/2min max 10min then 2mg in 1(/titrate rate

Theophylline: Tx hypokalemia, diazepam for fits,

Potassium -Low:

Ix: +/- ECG(Inverted T,U wave, PR (, ST (), repeat K+ 6h/cm

Rx: 5.0: Resonium 15g stat/30g fleet & 15g 8h po

> 5.5: add glucose 50% 40mls(dilute w/ N/S) + insulin 6U i/v

> 6.0: Calcium gluconate 10% 20mls slow i/v (cardioprotect), +/- neb ventolin: N/S 1:3 stat. ECG, Cardiac monitoring. +/- Hemodialysis.

Stop K+ sparing diuretics, treat ARF(eg hydration)

Sodium –Low (Non-milk diet. Rx: i/v 2-3( N/S + 2(D5%/24h. stat doses of i/v N/S if dry. I/v maxalon 10mg tds/prn.Kaolin 10mls tds if severe diarrh. Ciprofloxacin if septic.

Hepatitis

Ix: 3tubes,LFT. Acute Hep Sero, ?CMV, EBV. LFT/PT,PTT eod.

Rx: Vit B ‘/’ om. Low fat diet. Stop hepatotoxic drugs.

Hepatic encephalopathy

Ix: 4tubes, Ca/Mg/P, ABG, Bld C/S. (FP.

Rx:i/v multivit 10mg, i/v thiamine 100mg, i/v vit k 10mg x 2/7. Lactulose. Folic acid, vit b co, sangobion. Propranolol.

Low protein diet.

Heme-Onco

Anemia

Hx: Diet, Gastritis, NSAIDs, Menorrhagia

PE: PR, Postural BP

Ix: 4 tubes, LFT, ECG, Fe,TIBC/Ferritin(Plain tube), B12,Folate(Plain tube, FBC form), PBF, Retic.(FBC tube)

+/- Hb Electrophoresis, +/- Stool OB x 3/7. kiv OGD.

Rx: RIB, O2. 1( PCT/4 hours (after workup up) if Hb < 8-10.

Lasix 20mg with PCT if overloaded/phx IHD.

Blood reaction

Ix: Fill form. GXM tube, Grey tube. Hourly parm, +/- O2.

Rx: Hydrocort, Piriton.

Blood transfusion/call BTS MO (on call)

Know: Hb, blood group, Dx, symptomatic/bleeding? pre-op?

Call 62238793(office hr)/97342721. Document reply.

Check blood: Num on tag vs packet. Name on tag vs pt. Sign. Lasix?

DIVC screen (PT/PPT tube & form)

Ix: Fibrinogen((), D-dimer >0.5, soluble fibrin monomer

DVT

Ix: Leg circumference. d-dimer, Anticardio lipin Ab. Duplex scan.

Rx: S/C clexane 1mg(0.1ml)/kg bd

Neutropenic sepsis

Ix: 3tubes, LFT, Bld C/S, ECG, CXR, Ufeme & C/S

Rx: i/v cetriaxone 1g om + i/v genta 80mg tds OR i/v fortum 2g bd + i/v amikacin 7.5mg/kg bd if nosocomial

PT/PTT raised (pre-op)

No i/m injections, fall precautions, RIB.

Ix: LFT, +/- DIVC screen (see above). Recheck pt/ptt .

Rx: i/v vit k 10mg om x 3/7 for raised PT. 500mls FFP 8 hourly if for invasive procedure. Inform surgeon. Not for spinal/epidural.

ID

Dengue

PE: Bleeding, Postural BP

Ix: 4tubes, LFT, Dengue Sero, BFMP, +/- Bld C/S

Ufeme, Stool OB, Daily FBC, CRIB, Notify. No i/m inj (if plt low)

Rx: Paracet

Malaria

PE: Cerebral, pulmonary cx, Postural bp (hypovol)

Ix: FBC (Hb < 8), PBF (for schizonts), BFMP. LFT (Cr > 205, Bil > 50). PT/PTT kiv DIVC screen. Bld C/S. G6PD level(FBC tube). Kiv Dengue, wwF. +/- BFMP x2 12 hourly (finger prick & smear)

H/c 6h (hypoglyc).

Rx: Chloroquine 600mg stat and 300mg om x 3/7

If toxic, above criteria +ve, or BFMP falciparum: Quinine: Load (wt x20) in 1( D5% i/v over 4h then (wt x 10) in ½( D5 over 4-8h bd-tds

PUO

Ix: CT Abdo-pelvis. 4 tubes, LFT, Bld C/S, wwf, dengue, BFMP. CMV, EBV, HIV, Meliodosis. TB, Mantoux. ESR, ana, Anca, dsDNA. (2-(glob, LDH, CRP. FT4, TSH. Ufeme, C/S. Sputum.

Sepsis ?source – see also Fever (DIM)

Ix: 3 tubes, Bld C/S(1-1,2-2,1-1-1(fungal)). CXR. Ufeme, C/S(or dipslide if strong suspicion UTI after office hours). Sputum gram stain +C/S if coughing. Rx: Paracet, i/v antibiotics afrer C/S up. Guidelines:

Cellulitis: Cloxacillin 0.5-1g 6h + CP 2mu 6h/Ampicillin 500mg 6h

GE, severe: >6x, fever, toxic: Ciproflox 500mg bd po/400mg bd i/v

Meningitis: ceftriaxone 2g bd i/v after bld c/s but before LP

Neutropenic sepsis: (1)Ceftriaxone 1g om + Gentamycin 120mg om

Or (2)Imipenem 0.5g 6h i/v or cefepime 2g om or Fortum 2g bd i/v + amikacin 7.5mg/kg bd i/v or . Regime varies by dept/hsptl.

Peritonitis - SBP: ceftriaxone 2g om i/v

Peritonitis - perf: Ciproflox 400mg i/v 12h + Flagyl 500mg i/v 6h

Pneumonia, mild: Amoyxcillin/Augmentin po + EES. Alt: Clarithro.

Pneumonia, CAP: ceftriaxone 1g om i/v + EES 800mg bd po

Pneumonia, CAP, severe: above + cloxacillin 1g 6h i/v

Pneumonia, nosocomial: imipenem 500mg 6h or pip-tazo 4.5g 6h

Pneumonia, aspiration: ceftriaxone + metronidazole 500mg 8h i/v

Septic arthritis: tap, i/v ceftriaxone 1-2g qds + ?cloxacillin 1g 6h

Septic shock: imipenem 0.5mg 6h i/v or meropenem 1g 8h

Thrombophlebitis: cloxacilln 500mg 6h x 2/7, GMS dressing

UTI: urine dipslide, i/v ceftriaxone1g om, or po ciprofloxacin 250mg bd or po bactrim ‘’/’’ bd or po augmentin 525mg bd

Neuro

Bell’s palsy (usu not admitted unless to excl stroke)

Ix: EBV, HSV, CMV, ESR. Blink reflex.

Rx: Pred 40mg om x 2/7 -> 20mg om x 5/7. Eyedrop/shield.

CVA

Ix: +/- CLC 4 hourly. NBM/NG feeds if dysphagia. PT/OT/ST.

3 tubes, LFT, Ca/P. ESR, VDRL, fasting lipids & glucose. ECG, CXR U/S carotids, CT head (usu already done, non-contrast)

Rx: Aspirin 100mg om + famotidine 20mg om-bd, after excl. CI.

BP up to 160/100 normal post-CVA: don’t treat.

Drowsy/Confusion

Causes: Structural, infective, metabolic, drugs, any organ failure

Ix: h/c stat. +/- CLC. Off sedatives.

Ix as for provisional dx: Struc: CT head + CVA workup. Infective: septic workup +/- LP. Metab/drugs: 4 tubes, SpO2, ABG, toxi.

Epilepsy/Fits

Ix: h/c stat. 100% O2. I/v plug 2 tubes, anti-epileptic levels (send all if unsure), LFT, CK, CKMB, aldolase. Later: ABG, bld C/S. CT head.

Rx(Pt fitting):Diazepam 5mg slow bolus max 15mg. 2nd line: phenytoin 20mg/kg (undiluted, or in a line running N/S) with BP and cardiac monitor.

If h/c < 4: i/v D50% 40mls (with thiamine 100mg i/v if ?alcoholic)

Maint: Phenytoin 300mg 6h x 3 then 300mg om

Giddiness, postural hypotension

Causes: CNS, Vestibular, Cardiac, Metab/drugs

PE: Nystagmus, cerebellar s/s, postural BP, Hallpikes, gait

Ix: 4 tubes, Cenz, h/c, ECG,

Rx: Stugeron ‘/’ tds/prn, Stemetil 10mg tds/prn

LP/Meningitis

Ix: Consent, CT head, h/c, Plt & PT/PTT. Opening P. Fluid for: (1-clearest)Feme(tw/gluc), (2)G Stain and C/S, (3)AFB and TB C/S, (4)Fungal smear and C/S. kiv for (5)Latex agglutination, (6)Neurotrophic viruses, (7)VDRL, (8)Cytology

Rx: i/v ceftriaxone 2g stat & bd after bld c/s, before LP/CT.

Renal

Diet

Pre-HD: Cr < 300: Prot 1g/kg/d. >400: 0.6-0.8g/kg/d

HD: Prot 0.8-1g/kg/d, low K, Na+,fluid 500+urine

CAPD: Normal Prot(60-80g), K. Na and fluid restrict.

Dialysis pt

Hx: Dialysis days/center. Last HepB/HIV. Fluid restriction.

Ix: 3tubes, ABG, ECG, CXR. Inform Renal MO cm. No BP/blood taking L/R arm.

Rx: Fluid restrict. DM/low salt diet. O2. i/v lasix 120-240mg if overloaded and still having PU. Urgent HD if SOB++/K+ high.

Nephrotic syndrome

Ix: 3 tubes, Hep B,C, ANA, dsDNA, ANCA, RF, F Lipids. Ufeme, C/S, 24UTP, CCT. ECG. CXR, XR T/L spine. IO chart, daily wt. U/S kidneys.

Rx: Fluid restrict 500. i/v lasix 80mg tds + span K. Don’t start pred.

Pyelonephritis

Ix: 3tubes, Bld C/S, Ufeme + C/S. Genta levels

Rx:Cefzolin 1g 6h + Genta OR i/vCiprofloxacin 250mg 12h OR Renal impair: Ceftriaxone 1g stat+om

UTI

Ix: 4tubes, Bld C/S, Ufeme & dipslide before ab

Rx: ceftriaxone x 5/7/ Bactrim(nephrotox)/ Cipro/Augmentin

Catheter assoc + S/S: kiv trial off catheter, ab x 14/7.

Respi

Asthma(Reversibility)/COPD

Ix: 2tubes, ABG(on x l/min), ECG, CXR, Peak Flow. (asthma)

Rx: i/n O2 2L/min, +/- rib. Off (-blockers.

Neb ventolin:N/S 1:3(asthma) or ventoline:atrovent:n/s 1:1:2(COPD) 2-6 hourly, i/v hydrocort 100mg 6h or pred 10-30mg x 3/7. Rx any pneumonia.

Hemoptysis

Ix: 4tubes, LFT, hemoptysis chart(>25 x1 or >300/24h). Sputum C/S. +/- cytology. +/-TB ix. +/- blood C/S if ?pneumonia. CXR(Bronchiec). Kiv E-bronch

Rx: procordin 10mls tds. If massive(die from asphyxia, not blood loss): Lie on affected side(see CXR). 100% o2. Suction. Intubate (kiv w/ 2 lumen ETT). E-bronch.. kiv pulmonary art. embolization.

PE

Ix: 4 tubes, ABG + A-a gradient. Spiral CT. V/Q scan if spiral CT contraindic. Duplex LL.

Rx: 100% O2, Clexane bd

Pleural tap

Consent. Ix: Serum: LDH, LFT, +/- tumour markers

Fluid: 1 + ABG tube: Feme, protein, LDH, pH 2:G stain and C/S. 3: Cytology. 4:AFB, TB C/S 5:Fungal 6:Cryptococal Ag

Lights: Any of: Pl/serum: TP>0.5, LDH>0.6. Pl abs: LDH>200.

Pneumonia

Ix: 3tubes, ABG, Bld C/S, +/- mycopl/leg/chlamydia sero

Ufeme + C/S, Sputum stain + C/S, AFB smear + C/S

kiv laryngeal swab for AFB & TB C/S x 2/7, mantoux

Rx: i/n O2 2L/min. Chest physio

Ceftriaxone 1g stat+om, EES 800mg bd/tds, paracet

Hsptl acq: cefepime/pip-taxo (Pseudomonas)

Aspiration: Metronidazole

Allergy to penicillins: EES/Doxycyclin/Clarithromycin

Pneumothorax

Ix: 4 tubes(2 if small), SpO2/ABG, CXR (in full inspiration), ECG

Rx: 100% O2(even if not SOB) -> Chest tap -> Chest tube (4 tubes, consent, repeat CXR post tube).

Shortness of breath (on call)

Get dx , increase O2 over phone except COPD. Read casesheet.

Ix: 3tubes, SaO2/ABG, +/- Cenz & ECG, +/- CXR. +/- PE ix.

Rx: O2 (keep < 4L/min if known Type 2 RF), tx cause

Pre/Post op / procedure

Pre-op prep. “PFO – Prepare for op”

All: Listing, OT chit, consent. NBM 12mn(except under LA). Premeds “on call to OT”: Eg i/v cefazolin 2g

40, minor: FBC, U/E, ECG, CXR

major: FBC, U/E, CXR. if > 40, +ECG

Rheumatoid Art going for GA: C-spine (Flex/Ext)

Bronchoscopy: FBC, ECG. PT/PTT if for TBLB. I/m pethidine 30mg + i/m atropine 0.6mg(CI: Tachycardia, phx AMI) on call to ot

OGD: NBM 12mn.

Bowel Prep (colonoscopy): Low residue x 3/7, feeds only x 1/7, PEG 2L/Oral fleet 45ml bd x 1/7 before +/- Fleet enema few hours before.

Post-op review

Read op findings, post-op instructions and copy.

Check: VS stable. Dressing not soaked? (don’t open!), drain unclamped, drain not excessive. Distal perfusion & neuro ok.

Order: Hourly parm, O2, pain relief, 1st dose of stuff, Feeds->DOC, STO x POD.

Interventional radiology (TACE, Angiogram, Hickman’s, etc)

PE: Femoral pulse

Ix: Consent, 4 tubes, LFT, Cr (, Hb>8, Plt > 100k, PT/PTT

Pre: +/- n-acetylcysteine 600mg bd if Cr raised

Post-op: Examine wound site. RIB. Hourly parm, circulation chart x 6h. Pain relief.

Tap/tubes/Cope loops

Consider sedation and LA.

Send for:1)Cytology 2)C/S, Gstain 3)TB C/S, AFB.

4)Biochem: FEME, TW, glucose,

Pleural: 5)LDH, TP, SG, pH(ABg tube) 6) Serum h/c, LDH, TP.

LP: 5)Cryptococcus stain & Ag. 6)Specialized tests as ordered

Joints: 5)Crystals

Document: . and complications explained to pt. Performed by under aseptic technique at . Successful first attempt. . 20mls of straw coloured fluid obtained and sent for . No cx, patient tolerated procedure well. Lie flat, hourly parm x 6 and CXR.

GS

Acute abd

Ix: PR. 4 tubes, amylase, LFT, Ca+, Cenz. H/C. Urine diastase, pregnancy test. Ufeme, C/S. ECG, AXR, CXR(sitting/erect/L lat decub AXR). Hourly parm, NBM. Kiv CT abdo-pelvis. PFO.

Rx: i/v fluids. Pain relief(strong relief only if confirm op). Ciproflox 400mg 12h i/v or Ceftriaxone 2g om, Metronidazole 500mg 8h i/v.

ARU / BPH / Catheterization

Ix: PR, Ufeme, C/S, FBC, U/E/Cr, +/- PSA +/- KUB

Rx: Catheterize if pain/UTI/ARU. 12 small, 16 big. Replace foreskin.

C/I: Pelvic #, prostatitis.

“In-out cath”: Cath, measure amt, if < 300mls, remove cath.

Suprapubic cath falls out: Use normal foleys, insert through track as per normal ASAP before track distorted. Call uro ASAP if can’t cath.

Cholecystitis/ biliary colic/ cholangitis.

Ix: 4 tubes, amylase, LFT, Cenz, Bld C/S. Urine diastae. AXR(10% gallstones). U/S HBS. NBM.

Rx: i/v fluids. Pain relief. Ciproflox 400mg 12h i/v or Ceftriaxone 2g om, Metronidazole 500mg 8h i/v.

IO

Ix: PR +/- flatus tube. 4 tubes, LFT, Cenz. H/C. ECG, AXR, CXR(sitting/erect/L lat decub AXR). Hourly parm, NBM. I/O chart. Kiv CT abdo. PFO esp if large bowel(haustra incomplt cross) >8cm , RIF tender, BS ++.

Rx: drip & suck(NG tube on intermittent suction). Fleet enema. Ciproflox 400mg 12h i/v or Ceftriaxone 2g om, Metronidazole 500mg 8h i/v.

Testicular torsion

D/dx: Epididymitis(>30yrs old usu), UTI, tumour, trauma, hydrocoele.

Ix: 4 tubes. +/- urgent U/S testes. PFO. Consent for kiv orchidectomy & bilat orchidopexy.

Rx: Pain relief, PFO.

Ortho/Eye

Eye emergencies

Redness + Pain + decreased Va + = glaucoma/keratitis/iritis

Blindness(sudden) + RAPD + white fundus & pale disc = CRAO

Peripheral vision loss +/- “curtain” +/- floaters = retinal detachment

Head injury(Stable)/”Patient fell down”

Hx, PE: VS, Scalp, pearl, GCS, joint ROM, bony pain.

Ix: Xrays/CT head. 1-6 Hourly parm, CLC. Need incident report? Need police case?

Fractures

Xrays. Only emergency # needing op tonight are: (1)Spine with cord compression/instability (2)Hip # if pt ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download